1. Field of the Invention
The present invention relates to a method and system to standardize, encode, and process healthcare provider billing, more particularly, a computer assisted system for encoding, describing and processing fee charges for specific procedures of non-conventional medicine. The process and system compiles provider and patient data by geographical location, specifically by state, for any alternative practice and produces a universal set of codes to identify fees falling within a legal or regulatory scope associated with a provider's practice.
2. Description of the Prior Art
An objective of non-conventional medicine providers is to become enrolled into managed care networks wherein fee prices and payment for each procedure can be negotiated for the mutual benefit of patients, providers and payers. However, a number of obstacles exist.
At present, non-conventional medicine is understood to include a wide range of types of medicine and professions, including, but not limited to, alternative, holistic, complementary, or integrative healing. Moreover, each profession as understood by the term non-conventional medicine further varies by state due to legislative differences in licensing and like regulatory controls.
Also, conventional payers of healthcare costs, such as insurance companies, managed care organizations, Medicare and Medicaid, etc., fail to presently understand the alternative procedures being used by alternative professionals, and therefore do not have the information to underwrite health policies. Consequently, claims made by alternative healthcare professionals are being denied by payers.
Yet, no claims payment system exists to adequately address these problems. The system and method according to the present invention has been developed to overcome each of these problems, thus providing the benefit of permitting comparison of conventional treatment costs to non-conventional treatments as they diverge from well-known diagnostic codes, i.e. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).
The American Medical Association currently controls the ICD-9-CM and current procedural terminology (CPT) codes used to diagnose and to bill for conventional medicine. These codes are an insurance industry standard by which to bill and process medical claims by payers. Claims payment systems, relying on negotiations with providers for managed care solutions, depend on these coding systems to match charges with treatments, translate costs into statistics to identify costs, underwrite health insurance policies, and track patient outcomes and patient utilization.
As alternative medicine is brought into mainstream medicine, alternative providers have attempted to use these codes; but their claims are not understood by the payers because accurate descriptions of the services they perform do not exist therein.
Furthermore, ICD-9-CM and CPT codes do not identify the practitioner by profession. For these reasons, "dummy billing codes" or codes designed by individual payers to cope with payment for alternative treatments have been developed by a few carriers which offer payment benefits to alternative medicine. Likewise, state Medicaid and workers' compensation codes have been modified to cope with integration of acupuncture and naturopathy into each system.
In each of these instances, the source of the descriptions of alternative services or treatments originate not from schools or associations of alternative medicine which are able to properly identify and describe each treatment, but rather from the payers themselves. Therefore, unfortunately, these description codes are not comprehensive and fail to account for all services performed in the office of an alternative provider. Therefore, no independent system presently exists to cope with the need for the exchange of information in this field of health care, and none can be expected to evolve from CPT codes of the American Medical Association, whose mission is to promote treatments used by conventional medical doctors and which organization is not trained to understand alternative treatments. The present result is that alternative health care cannot be widely used by the existing payer systems, such as Medicare and Medicaid, until the descriptions of treatments by alternative practitioners is put into standardized terminology and given corresponding codes.
As an added complication, a working system must also incorporate the licensing and "scope of practice" regulations of each state in order to be useful to the payers.
Finally, alternative codes should be distinct from CPT. Cost outcome studies with conventional treatments depend on this distinction and are crucial to payers to underwrite the cost of adding alternative medicine and to meet consumer demand.
Thus, the present system and method takes advantage of the failures of the current coding system to provide accurate data and a universal terminology for alternative medicine in a state-specific format. By providing a system to which the alternative healthcare provider may attach a code to a valid description of services, the benefit of having alternative treatments added to insurance coverage can be attained.
No national system of encoding or processing alternative healthcare provider billing is known in the prior art. However, among traditional healthcare billing systems, several methods and systems are known. For example, U.S. Pat. No. 4,491,725, issued Jan. 1, 1985, to Pritchard, describes a medical claim verification and processing system in which a medicard is used to access a central brokerage computer for patient information for implementation of a method to rapidly determine an insurance claim payment for a specified patient service. The computer stores a code conversion table for each possible paying insurance carrier for converting patient treatment codes into service codes associated with a claim payment. The end result is an increase in the speed of processing of information, which enables the provider and patient to rapidly assess the current status of the payment of a claim by an insurance carrier. Such system fails to provide a method of encoding non-traditional types of healthcare treatments.
Moreover, such system and others like it apply only to preexisting systems of codes, such as CPT codes adopted by many insurance companies and the federal government for Medicare reimbursement. CPT codes are standard patient treatment codes, as set forth by the American Medical Association and adopted by the federal government for Medicare reimbursement claims. As part of a more comprehensive system, CPT codes set forth a five digit code to identify a particular type of procedure in each of five main procedure rubrics: Medicine; Anesthesia; Surgery; Radiology; and Pathology. Each code typically covers a category of specific medicinal procedures, as well as other ancillary information, such as the location of such procedure (e.g., emergency room, outpatient office visit, etc.) and the duration of such visit. Such information is requested by the payer to properly analyze whether reimbursement of payment claims for patient services by the provider is warranted. As noted, the CPT codes have become highly popular and are being adopted by insurance companies to analyze the appropriateness of a claim for payment.
However, CPTs are, at the least, cumbersome and expansive, and often confuse the practitioner which CPT code to use. For example, in cases where certain specialties perform procedures which cross many sub-specialties, the procedures fall into more than one of the numerated rubrics of CPT codes, and the burden on the practitioner to learn the proper classification becomes particularly undue.
Therefore, systems have been developed to try to automate the function of selecting the proper CPT code. For example, and as described in U.S. Pat. No. 5,325,293, issued Jun. 28, 1994, to Dorne, a system to correlate medical procedures and medical billing codes for interventional radiology procedures includes generating raw codes which correspond with selected medical procedures and then analyzes the raw codes to generate a set of intermediate codes, which account for the interrelation of the selected medical procedures, without altering the raw codes. The billing codes are then generated from the intermediate codes.
To determine appropriateness of a treatment for a procedure, even when the procedure has been properly classified under a CPT code, the procedure must be appropriate to the diagnosis before payment is made by a payer. Another system is discussed in U.S. Pat. No. 4,667,292, issued May 19, 1987, to Mohlenbrock, et al., wherein the use of a computer system is provided for identifying the most appropriate billing categories, namely Diagnosis Related Groups (DRGs), as also set forth by the federal government for Medicare reimbursement. The Medicare payment system requires first encoding diagnostic (ICD-9-CMs) and procedural (CPT) information, which steps are dependent upon several factors, including a principal diagnosis of the patient's problem, the procedures performed upon the patient, the age of the patient, and the presence or absence of any complications or co-morbidity, DRGs are determined in part by the ICD-9-CM coding system, which refers to a coding system based on a compatible with an accepted, original system of classification system provided by the World Health Organization. The ICD-9-CM codes are used in North America, being a classification of diseases, injuries, impairments, symptoms, medical procedures and causes of death. The ICD-9-CMs are initially divided into Disease and Procedure sections. These sections are further subdivided into subsections which encompass anywhere from 1-999 three digit disease or 1-99 two digit procedure code categories. Within the three digit code categories, there can be an additional 2 or digits to divide the codes into subcategories which further define either or both the disease manifestations and diagnostic procedures. There are approximately 15,000 ICD-9-CM codes, of which only a fraction are useful in the Medicare payment system, and even less are relevant to determining patient services of alternative healthcare providers.
The Mohlenbrock et al. System is clearly only directed at aiding in a determination which one of the large number of the predetermined list of payment categories is appropriate for reimbursement of a provider and providing a thorough and complete billing for maximum Medicare reimbursement under the Medicare system. Unlike the present system and method, the means are not directed at categorizing patient record and provider billing information by valid terminology and a corresponding code specific to alternative medicine and by state scope of practice for each provider type.
Other systems are also known for organizing medical information into useful codes. In U.S. Pat. No. 5,002,630, issued Mar. 19, 1991, to Wiltfong, a business system comprising means for coding client histories, listing plural procedures, terms or remarks used in a specific office or business with a distinct alphanumerical indicator. The coding of these factors is directed to sequencing veterinary procedures most frequently used in an office, and systemized into an index of broad categories called a procedural index in which each requires financial consideration to be entered when such procedure is provided. A chain of alphanumeric indicators can then be constructed to identify the procedure, terms or remarks. However, such system is directed not at systemizing the billing external to the office, but is primarily intended as an internal housekeeping measure.
None of the above inventions and patents, taken either singly or in combination, is seen to describe the instant invention as claimed.